Health system needs more than just a sticking plaster

Without the restoration of trust, a crisis could cause our health system to implode, write Kerry Goulston and Bruce Robinson.

We have both worked in public hospitals for more than 25 years, and have never seen the system under such pressure.

We need to learn from system mistakes where they occur. But we should not lose sight of the fact that there are hundreds of thousands of surgical procedures performed and patients managed each year to a very high standard.

Despite media interest in contentious cases of medical treatment, the Australian health system is one of the best in the world.

There are tens of thousands of doctors, nurses and allied health professionals in NSW public hospitals committed to helping sick patients, striving to do their utmost for each in circumstances where they feel under increasing strain. Productivity in our hospitals has significantly increased over recent years. Patients stay a shorter time; many are treated on a "day-only" basis; diagnostic tests and therapies are more numerous and more sophisticated; and the patients are older and sicker than those 10 years ago.

These factors place increasing demands on hospital health care workers, many of whom are becoming frustrated, angry and cynical. They want the best for their patients, for whom they feel passionately, yet they see "Band-Aid" measures which do not address the real problems, poorly co-ordinated national health policies, an adversarial political system, and media that highlight mishaps while not publicising systemic problems.

Waiting times for elective surgery are long and surgeons are frustrated for their patients when their operating lists are cut. Emergency departments are frequently overstretched. The working hours of junior and senior doctors remain high and potentially unsafe, and the expectations placed on nurses and allied health workers continue to increase.

For these reasons, workforce issues are the biggest challenge facing the health care system. Australia needs a co-ordinated workforce plan to deal with projected increases in demands for health services. This will require co-operation of the Commonwealth, the states and territories and bodies such as the medical colleges. Entrance into all health care programs at universities is capped, and many competent and committed young Australians are being turned away.

There is an impending workforce crisis already evident in some hospital medical specialties, in nursing and in some allied health fields. This is most worrying in outer metropolitan and rural hospitals. In addition to patient care, the public hospital system carries the vast workload of training health professionals.

In medicine, much of this is done by doctors on top of their other responsibilities and for no financial reward. The private health care system contributes little to training but draws its workforce very largely from health care professionals originating in the public system.

Many Australians would prefer better health services rather than tax cuts. Government funding is not increasing fast enough to sustain even present levels of service, let alone the increasing pressures of an ageing population and innovations in medical technology. Excessive emphasis is being placed on adhering to health care budgets, and this is dictating the quality and quantity of health care that clinicians and hospitals can deliver.

Trust needs to be restored: trust between clinicians and managers, and between the community and those working in public hospitals. Otherwise the situation will worsen until a crisis occurs and the system implodes. We believe this is not far off. Why wait until then?

The community, media and federal and state politicians of all parties need to hear the cry of those working in our public hospitals.

There is an urgent need for bipartisan support for four initiatives: The number of training positions for health care workers in all fields must be increased. Government initiatives fall short of the expected needs of the community. Overseas, programs to train significantly more doctors have been introduced recently in Britain and Canada, and the need for such an increase has also been acknowledged in the United States. The reliance on overseas-trained doctors is not sustainable. Adequate funding must be provided. There should be a bipartisan state/federal push to allocate more money for hospital care. A federal budget surplus of $4.6 billion has been announced. In Britain, Tony Blair has increased taxes to spend more on education and health. Strong leadership is necessary. We need health professionals and managers who are not afraid to "tell it how it is". Clinicians and managers must work together, joined by community leaders. Priorities in health spending should be established. Even if more money is spent there is a need to construct a means for health care professionals and consumers to work with health planners to prioritise spending. Hard choices will have to be made, as finance will never be unlimited. In the long term, increased spending on prevention, health promotion, early detection of ill-health and community medicine is essential.

Area health boards need to be encouraged to expand community-based programs and keep patients out of hospital. This will not be achieved quickly.

In the short term, the crisis is here and now in our public hospitals. Health care workers and the community together can turn the tide. If we remain apathetic it may be too late.

Kerry Goulston is emeritus professor of medicine, University of Sydney, and chairman of the NSW Greater Metropolitan Transition Taskforce.

Bruce Robinson is professor of medicine, University of Sydney, and head of the division of medicine, Royal North Shore Hospital.